This invention relates to improved drug compositions useful in the treatment of male erectile dysfunction and also to methods of treatment. More particularly, this invention discloses specific formulations containing the pharmacological agents phentolamine mesylate, papaverine hydrochloride, and alprostadil (prostaglandin E1) in a novel buffer and the administration of such formulations to mammals (including humans) to treat male impotence.
Impotence is a common medical disorder affecting about 20 million men in the U.S. alone. Male erectile dysfunction has been defined as the inability to achieve or maintain an erection sufficient for intercourse (Impotence, National Institutes of Health Consensus Development Panel on Impotence Conference, JAMA 1993, 270 83-90). The dominant etiology for this condition is arterial insufficiency associated with cardiovascular disease. Male erectile dysfunction adversely impacts the quality of life, being frequently associated with depression, anxiety, and low self-esteem. Although male erectile dysfunction represents a major clinical problem, treatment for this condition remains problematic and unsatisfactory.
One of the least invasive therapies available entails the use of a vacuum constriction device on the penis to produce an erection. The physiology of the penis is such that blood flows in through arteries deep within the tissue while blood flows out through veins near the skin surface. By placing a plastic cylinder over the shaft of the penis and employing a vacuum pump to restrict venous blood flow from the penis, the corpus cavernosum penile tissue becomes engorged with trapped blood and an erection is produced. Common patient complaints are that this device is interruptive to the sex act, has a short duration of effectiveness, and can cause tissue damage to the penis, such as necrosis, with extended use.
Penile prosthesis implantation is an alternative treatment of erectile dysfunction. This therapy entails surgically implanting a mechanical device inside the penis (for example see U.S. Pat. No. 5,065,744 to Zumanowshky). This device can be a semi-rigid malleable rod or a fluid inflated tube which can be operated by the patient to achieve an erection. Although this method does not affect the ability to urinate, ejaculate, or have an orgasm, the surgery required to implant the prosthesis can lead to pain, infection, and scarring.
Recent insights into the physiological mechanism of penile erection have led to the development of other therapies for the treatment of erectile dysfunction. Preliminary studies have shown that during sexual arousal, nitric oxide molecules are released into the surrounding tissue from nerve endings and endothelial cells in the genitals. These nitric oxide molecules then cause the enzyme guanylate cyclase to produce cyclic guanosine monophosphate (cGMP) which lowers the level of intracellular calcium in the surrounding medium and allows for the relaxation of smooth muscle cells. In the penis, the relaxation of the corpus cavernosal smooth muscle cells permits increased blood flow into the cavernosal spaces which leads to greater intracavernosal pressure thereby producing penile rigidity.
It follows then that a pharmacological agent which inhibits the breakdown of cGMP would have the potential to prolong or enhance penile erections during sexual stimulation. The drug sildenafil (Viagra(trademark), Pfizer, Inc.) is one such pharmacological agent which, when given orally, has shown some success in this manner (Terrett, N. K. et al. Bioorg. Med. Chem. Lett. 1996, 6, 1819-1824).
Other types of oral therapies which are available to treat erectile dysfunction by different means include centrally-acting drugs such as atipamezole (Farmos Orion) which is an xcex1-adrenergic blocker, apomorphine (Pentech Pharmaceuticals) which is a dopaminergic agonist, and phentolamine (Vasomax(trademark), Zonagen) which is another xcex1-adrenergic blocker/vasodilator. This family of drugs appears to act by expanding arteries and relaxing penile tissue which, in combination, entraps blood in the penis thereby producing an erection. However, some oral therapies may have drawbacks with respect to efficacy and side effects. Therefore, in those cases it would be beneficial to treat impotence directly by administering medicaments directly on/into the penis itself These modes of administration may also minimize the dosage of the medicament needed.
One alternative route for administering vasoactive agents like those mentioned above is by transdermal administration to the penis. The compound alprostadil (prostaglandin E1) is formulated as a cream (Macrochem) which is absorbed into the penile tissue. Alprostadil has been shown to bind to specific receptors in penile tissue which is accompanied by an increase in cellular cyclic adenosine monophosphate (cAWP) levels. The physiological mechanism, as described with cGMP above, results in a decrease of intracellular calcium in the cytoplasm and the relaxation of smooth muscle cells. These vasodilatory effects result in rapid arterial inflow and expansion of the sinusoidal spaces within the penis. This action then restricts venous outflow from the penis whereby penile rigidity develops. Another vasoactive agent, papaverine hydrochloride, is formulated into a patch (PharmaPatch, Pharmedia) to be applied to the skin of the penis and acts as a non-specific phosphodiesterase inhibitor to maintain cGMP levels in a similar sort of mechanism as described above which produces an erection. These external treatments of the skin surface of the penis suffer from the drawback that the sex partner comes into contact with the drug during intercourse and can be adversely affected.
The above-mentioned pharmacological agents and routes of administration represent therapies for the treatment of erectile dysfunction which can be successful for about 75-80% of the 20 million men having erectile dysfunction. However, for the remaining impotent population, a different treatment is needed which often includes intraurethral and/or intracavernosal injection therapy.
Currently, there are two FDA-approved injection therapies available (Caverject(copyright), Pharmacia-Upjohn; and Edex(trademark), Schwartz Pharma), both of which employ alprostadil as the active component. Caverject(copyright) is commercially marketed as a freeze-dried powder containing the active ingredient alprostadil in a base of lactose, sodium citrate, and benzyl alcohol. When reconstituted with water, Caverject(copyright) is injected into the intracavernosal space of the penis. Similarly, EDEX(trademark) is a lyophilized powder containing alyrosal, xcex1-cyclodextrin, and anhydrous lactose. It is also reconstituted with water before injection into the intracavernosal space of the penis. A urethral suppository of alprostadil (MUSE(trademark), Vivus, Inc.) has also recently been introduced into the market; however, it has shown disappointing clinical results (Biotech. Newswatch, Jun. 15, 1998, 4-5). Not all impotent men respond to alprostadil therapy alone.
In order to treat these individuals who were non-responsive to alprostadil, Zorgniotti et al. (J. Urol. 133,39-41 (1985), incorporated herein by reference) demonstrated that the intracavernosal injection of a combination of papaverine hydrochloride and phentolamine mesylate rapidly produced transitory penile tumescence which could be followed by an erection in response to sexual stimulation.
Similarly, Althof et al. (J. Sex Marital Ther. 17(2);101-112 (1991), incorporated herein by reference) reported that intracavernosal injection of papaverine hydrochloride and phentolamine mesylate resulted in improved erectile ability in about 84% of patients injected. However, there was a high dropout rate (57%) in this study because 25% of patients developed fibrotic nodules, 30% had abnormal liver functions, and 19% experienced bruising of the penile tissue. In another study using the same combination of phentolamine mesylate and papaverine hydrochloride, the intracavernous injection of this combination led to marked penile fibrosis in the patients injected (see Larsen, E. K. et al. J. Urol. 137, 292-293 (1987) incorporated herein by reference).
Therefore, a need exists for a safe and effective alternative treatment for impotence which minimizes the drawbacks of the therapies described above to those currently available.
Compositions and methods for the treatment of male erectile dysfunction are provided. When injected into the corpus cavernosum, the compositions of this invention aid in producing, enhancing, or sustaining an erection of the penis. The compositions comprise one or more of the following pharmaceutically active agents: an xcex1-adrenergic blocker, a phosphodiesterase inhibitor, and a prostaglandin. Preferred xcex1-adrenergic blockers include phentolamine mesylate and phentolamine hydrochloride. Preferred phosphodiesterase inhibitors include papaverine hydrochloride, Sildenifil (Pfizer). Preferred prostaglandins include alprostadil, any pharmaceutically acceptable salts, hydrates, hemihydrates, ester or other pharmaceutically acceptable forms of the foregoing pharmaceutically active agents are also included within the scope of the invention. Other Class V phosphodiesterase inhibitors are also preferred. A preferred composition is a trimix comprising phentolamine mesylate, alprostadil and papaverine hydrochloride. Preferably, the trimix further comprises a buffer which buffer comprises a substrate for nitric oxide synthetase. A preferred substrate is arginine.
Preferred buffers include one or more substrates for nitric oxide synthetase. More preferred buffers comprise glycine, arginine, or mixtures thereof Even more preferably, the buffer comprises a mixture of glycine, L-arginine, mannitol, and benzyl alcohol in water. The foregoing buffers may also comprise other pharmaceutical excipient carriers and the like. The advantages to the use of these buffers in conjunction with the mentioned active agents include improved solubility profiles of the pharmaceutical agents and they provide substrates for the enzyme nitric oxide synthetase, which has been shown to play a role in the erectile response, and may result in a lower dosage requirement for efficacy.
The present invention is directed to improved compositions which, by way of a non-limiting example, comprise the vasoactive agents phentolamine mesylate, papaverine hydrochloride, and alprostadil (or any pharmaceutically acceptable salts of these vasoactive agents). Another aspect of the invention is directed to compositions comprising one or more vasoactive agents such as papaverine, phentolamine, and alprostadil in a buffer comprising either glycine, L-arginine, or a mixture of glycine and L-arginine. By virtue of the improved solubility profiles of the vasoactive agents in the buffers of the present invention, the use of the inventive compositions lowers the incidence of fibrotic nodules in the penis and priaprism caused by precipitation and depot formation of vasoactive agents at the site of injection. Without being bound by theory, it is also believed that the presence of L-arginine in the compositions of the invention or other substrates for nitric oxide synthetase may lower the effective dosage of the vasoactive agents in the compositions.
When compositions according to the present invention comprise only an xcex1-adrenergic blocker or a phosphodiesterase inhibitor or a prostaglandin as the pharmaceutically active agent, the composition will further comprise a buffer which buffer comprises a substrate for nitric oxide synthetase such as arginine. When the compositions of the invention comprise two or more of the pharmaceutically active agents described above, the compositions optionally comprise buffers which comprise a substrate for nitric oxide synthetase.
Particularly preferred for the present purposes is a composition comprising an xcex1-adrenergic blocker (e.g., phentolamine mesylate), a phosphodiesterase inhibitor (e.g., papaverine hydrochloride or Sildenifil), and a prostaglandin, (e.g., alprostadil) in a buffer. The active ingredients phentolamine mesylate, papaverine hydrochloride, and alprostadil are present in the composition in a weight ratio in the range of about 0.5:7.5:0.005 to about 5:30:0.02. More preferably, the weight ratio of phentolamine mesylate: papaverine hydrochloride: alprostadil is about 1:30:0.01.
Dosages of the vasoactive components of the invention are in the range of about 0-40 xcexcg/ml alprostadil, about 0-50 mg/ml papaverine, and about 0-10 mg/ml phentolamine in a total volume of about 0.5 ml. Preferred dosages of the inventive compositions are in the range of about 1.25-5 mg/ml phentolamine, about 7.5-30 mg/ml papaverine, and about 5-20 xcexcg/ml alprostadil in a total volume of about 0.5 ml. More preferably, the dose is about 1 mg/ml phentolamine, about 30 mg/ml papaverine, and about 0.01 mg/ml alprostadil in a total volume of about 0.5 ml.
In the case of a composition of the invention containing only phentolamine as the vasoactive agent in combination with a buffer such as an arginine and/or glycine containing buffer, the preferred dosage is about 1.25 mg/ml in a total volume of 0.5 ml. For a composition containing only papaverine in combination with an arginine and/or glycine contains buffer as the vasoactive agent, the preferred dosage is about 7.5 mg/ml in a total volume of 0.5 ml. In a composition containing only alprostadil as the vasoactive agent in an arginine and/or glycine containing buffer, the preferred dosage is about 5 xcexcg/ml in a total volume of 0.5 ml. Compositions comprising only two of the vasoactive agents in a buffer according to the present invention are also contemplated by the invention.
The active ingredients are administered in a buffer which enhances their solubility and/or provides a substrate for nitric oxide synthetase. The buffer preferably contains glycine, mannitol, and benzyl alcohol in water. In this buffer, the content of glycine is preferably in the range of about 1% to about 2% by weight. More preferably, the buffer contains L-arginine, glycine, and other pharmaceutically acceptable excipients such as mannitol, and benzyl alcohol in water. The weight ratio of L-arginine to glycine in this preferred buffer is about 1:20. The pH of the composition in buffer is from about 3 to about 7. A preferred pH range for the composition is from about 3 to about 5.
Also included in the present inventions is a method for the treatment of male erectile dysfunction which comprises administering a pharmacologically effective amount of a composition comprising an xcex1-adrenergic blocker, a phosphodiesterase inhibitor, and a prostaglandin. Preferably, in this method the composition comprises phentolamine mesylate, papaverine hydrochloride, and alprostadil in a buffer. In this method of treatment, the route of administration is a member of the group consisting of oral, transdermal, subcutaneous intraperitoneal, intramuscular, and intrapenile (including intracavernosal). A preferred route of administration is by intracavernosal injection.
The composition utilized in this method of treatment preferably comprises phentolamine mesylate, papaverine hydrochloride, and alprostadil in a weight ratio in the range of about 0.5:7.5:0.005 to about 5:30:0.02. More preferably, phentolamine mesylate, papaverine hydrochloride, and alprostadil are present in the composition in a weight ratio of about 1:30:0.01.
Dosages of the vasoactive agents useful in this method of treatment are in the range of about 0-40 xcexcg/ml alprostadil, about 0-50 mg/ml papaverine, and about 0-10 mg/ml phentolamine in a total volume of about 0.5 ml. Preferred dosages of the vasoactive agents are in the range of about 1.25-5 mg/ml phentolamine, about 7.5-30 mg/ml papaverine, and about 5-20 xcexcg/ml alprostadil in a total volume of about 0.5 ml. More preferably, the dose in this method is about 1 mg/ml phentolamine, about 30 mg/ml papaverine, and about 0.01 mg/ml alprostadil in a total volume of about 0.5 ml.
Methods utilizing a composition containing only phentolamine as the vasoactive agent, the preferred dosage rate is about 1.25 mg/ml in a total volume of 0.5 ml. For a method utilizing a composition containing only papaverine as the vasoactive agent, the preferred dosage rate is about 7.5 mg/ml in a total volume of 0.5 ml. In a method using a composition containing only alprostadil as the vasoactive agent, the preferred dosage rate is about 5 xcexcg/ml in a total volume of 0.5 ml.
The buffer used to solubilize the active ingredients in the foregoing methods comprises mixtures of glycine, mannitol, and benzyl alcohol in water. The glycine content of this buffer is preferably in the range of about 1% to about 2% by weight. More preferably, the buffer comprises a mixture of glycine, L-arginine, mannitol, and benzyl alcohol in water. The weight ratio of glycine to L-arginine in the preferred buffer is about 1:20. The pH of the composition of the invention in the buffer is from about 3 to about 7. Preferred is a pH from about 3 to about 5.
The present invention is further illustrated by the following examples which assess the increased solubility of the active ingredients phentolamine, papaverine, and alprostadil in a buffer comprising glycine and arginine and also the ability of the improved compositions to induce penile erection in rabbits upon the intracavernosal injection of the composition containing phentolamine mesylate, papaverine hydrochloride, and alpSMrostadil in buffer at various pH. The use of the composition of the present invention for treatment of impotence in humans is also provided.